Upper GI Bleeding: Ulcers, Varices, and Stabilization

When someone vomits blood or passes black, tarry stools, it’s not just unpleasant-it’s a medical emergency. Upper GI bleeding can happen to anyone, but it’s most common in older adults and those with liver disease or a history of NSAID use. The good news? With fast action and the right care, survival rates have improved dramatically. The bad news? Many people ignore early signs, delaying care until it’s too late.

What Causes Upper GI Bleeding?

Upper GI bleeding means blood is coming from the esophagus, stomach, or the first part of the small intestine (duodenum). The most common cause? Peptic ulcers. These open sores in the stomach or duodenal lining account for 40-50% of all cases. Most are caused by Helicobacter pylori infection or long-term use of NSAIDs like ibuprofen or aspirin. Gastric ulcers make up about 20-30% of ulcer-related bleeds, while duodenal ulcers are more common, at 70-80%.

Another major cause is esophageal varices. These are swollen veins in the esophagus, usually due to advanced liver disease and portal hypertension. About 10-20% of upper GI bleeds come from varices, but they’re dangerous-20% of patients die within six weeks without treatment. Unlike ulcers, varices don’t cause pain before they burst. They just… rupture. That’s why people with cirrhosis need regular screening.

Other causes include:

• Erosive gastritis (15-20%)-inflammation and erosion of the stomach lining
• Esophagitis (5-10%)-often from acid reflux or infection
• Mallory-Weiss tears (5-10%)-tears at the stomach-esophagus junction from violent vomiting
• Malignancies (2-5%)-stomach or esophageal cancer
• Portal hypertensive gastropathy (50-80% in advanced liver disease)
• Hiatal hernias (about 5%)

Even common medications can raise your risk. A 2022 JAMA study tracking half a million people found that those taking SSRIs (like fluoxetine or sertraline) had double the rate of upper GI bleeding compared to non-users. It’s not just NSAIDs anymore.

Recognizing the Signs

You don’t need to be a doctor to spot warning signs. If you or someone else has:

• Vomiting bright red blood (hematemesis)
• Vomiting dark, coffee-ground-like material (partially digested blood)
• Black, sticky, foul-smelling stools (melena)
• Maroon or bloody stools (hematochezia, usually with massive bleeding)
• Dizziness, fainting, rapid heartbeat, or low blood pressure

-it’s time to go to the ER. These aren’t symptoms you wait out. Melena means blood has been in the gut long enough to be digested. That’s not normal. And if your heart is racing while you’re lying still, your body is telling you it’s losing blood.

A 2023 Reddit post from user u/GIwarrior99 described waking up at 3 a.m. coughing up coffee-ground material. He went to the ER, got three units of blood, and spent eight days in the hospital. His story isn’t rare. A University of Michigan study found 68% of survivors still felt anxious about another bleed just 30 days after discharge.

How Doctors Diagnose It

The first step isn’t an endoscope-it’s stabilization. If someone is dizzy, pale, or has a heart rate over 100, they need fluids and oxygen before anything else. Then, doctors check:

• Hemoglobin-a level below 7 g/dL usually means significant blood loss
• BUN-to-creatinine ratio-a ratio above 30:1 has 68.8% sensitivity for upper GI bleeding
• INR-to check clotting function, especially if liver disease is suspected

But the real game-changer is the Glasgow-Blatchford score. Developed in 2000 and updated in 2019, it uses six simple factors: hemoglobin level, blood pressure, pulse rate, melena, syncope, and history of liver or heart disease. A score of 2 or higher means hospitalization is needed. A score of 0? You might be able to go home safely.

Dr. Robert Logan from Harvard says this score has revolutionized triage-15% of patients can be managed as outpatients now. That’s a huge shift from 20 years ago, when everyone got admitted.

Once stable, the next step is urgent endoscopy. The American College of Gastroenterology recommends getting an esophagogastroduodenoscopy (EGD) within 24 hours. But if you’re high-risk, waiting even 12 hours can cost lives. Studies show endoscopy within 12 hours cuts mortality by 25%.

What Happens During Endoscopy

During the procedure, doctors use the Forrest classification to rate bleeding risk:

• Class Ia-spurting blood. 90% chance of rebleeding without treatment.
• Class Ib-oozing. 50% rebleeding risk.
• Class IIa-visible vessel. Also 50% risk.
• Class IIb-adherent clot. 20-30% risk.
• Class III-clean base. Less than 5% risk.

If you have Class I or IIa, they’ll treat it immediately. For ulcers, that usually means injecting epinephrine to constrict blood vessels, then using heat or clips to seal the spot. Success rate? 90-95%.

For varices, they use band ligation-tiny rubber bands slipped around the swollen veins. It’s more effective than older methods like sclerotherapy, cutting rebleeding rates from 60% to 25%.

Treatment: Ulcers vs. Varices

Treatment depends on the cause.

For ulcers:

• High-dose IV proton pump inhibitors (PPIs): 80 mg bolus, then 8 mg/hour infusion
• This drops rebleeding from 22.6% to 11.6%, according to the 2022 COBALT trial
• Test for H. pylori and treat if positive
• Stop NSAIDs and SSRIs if possible

For varices:

• Immediate vasoactive drugs: terlipressin or octreotide
• Antibiotics: ceftriaxone 1g daily to prevent infections
• Band ligation within 24 hours
• Long-term beta-blockers to reduce portal pressure

Transfusions are used when hemoglobin drops below 7 g/dL or symptoms of anemia are present. Each unit of packed red blood cells raises hemoglobin by about 1 g/dL. But don’t overdo it-target 7-9 g/dL. Giving too much blood can increase complications.

The Stabilization Bundle

Hospitals that use a standardized “Upper GI Bleed Bundle” have seen big improvements. Massachusetts General Hospital’s version includes five steps:

1. Assess and stabilize within 30 minutes
2. Calculate Glasgow-Blatchford score
3. Give PPIs within 1 hour for high-risk patients
4. Perform endoscopy within 12 hours
5. Follow up with GI specialist within 72 hours

Before this bundle, patients waited an average of 24.5 hours for endoscopy. Now? It’s 9.2 hours. Mortality dropped from 8.7% to 5.3%.

What’s New in 2025

Technology is changing how we treat this. In 2023, the FDA approved Hemospray-a powder that forms a temporary seal over bleeding sites. It’s not a cure, but it buys time for patients who are too unstable for standard endoscopic treatment.

Even bigger: AI-assisted endoscopy. The 2023 ENDOSCAPE trial showed AI systems spotted bleeding signs with 94.7% accuracy-far better than human endoscopists at 78.3%. Dr. Thomas Wang predicts all major hospitals will use AI tools within five years.

But there’s a catch. Stanford’s Dr. Susan Chang warns current AI models are less accurate in Black and Hispanic patients because training data lacks diversity. That’s not just a tech problem-it’s a health equity issue.

Meanwhile, the NIH’s UGIB-360 study, launched in January 2024, is tracking 10,000 patients to build personalized risk models using genetics, gut bacteria, and clinical history. Results are expected in late 2025.

What Patients Should Know

If you’ve had an upper GI bleed:

• Don’t restart NSAIDs without talking to your doctor
• Limit alcohol-especially if you have liver disease
• Follow up with a gastroenterologist, even if you feel fine
• Ask about H. pylori testing if you haven’t had it
• Consider switching SSRIs if you’re at high risk

One Reddit user, u/StomachSOS, waited two weeks when his doctor dismissed his black stools as “just iron supplements.” He ended up in the ER with a hemoglobin of 5.8-half the normal level. That’s the kind of delay that kills.

And yes, you’ll probably be anxious. That’s normal. But knowing the signs and acting fast can save your life next time.